Provider Demographics
NPI:1457097552
Name:GARD, MADELYN
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:GARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 E KELTON LN UNIT 1062
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1005
Mailing Address - Country:US
Mailing Address - Phone:623-466-5202
Mailing Address - Fax:
Practice Address - Street 1:21001 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4206
Practice Address - Country:US
Practice Address - Phone:877-222-5348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
9111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant